VOL: 98, ISSUE: 25, PAGE NO: 59
Maria Poole, RGN, DPSN, BSc, is clinical nurse specialist in wound care, and Anne Coughlan, RGN, DIP(CHS), is wound care sister, South Staffordshire Healthcare NHS TrustMaria Poole, RGN, DPSN, BSc, is clinical nurse specialist in wound care, and Anne Coughlan, RGN, DIP(CHS), is wound care sister, South Staffordshire Healthcare NHS Trust
In 1999 a general practice in South Staffordshire refused to prescribe sterile dressing packs for wound management purposes. The reason given was that the use of these packs was not evidence-based and that this negated the need for them, resulting in considerable cost-savings. While I generally agreed with the assumption, it presented me, the clinical nurse specialist in wound care for a community trust whose current aseptic wound dressing procedure included the use of a sterile dressing pack, with a dilemma.
The trust already had a clean wound dressing procedure that did not involve the use of a sterile dressing pack. This gave clear guidelines indicating when it should be implemented, and an education programme was in place to promote its use. These guidelines also outlined when the aseptic wound dressing procedure should be implemented. This posed the question: could the principle of asepsis (Gilmour, 1999) be adhered to without the use of a sterile dressing pack?
A literature search was carried out to establish whether there was any published evidence to support the use of sterile dressing packs in wound management as best practice. The search included sources that provided both national and international literature and consisted of both manual and computer searches.
No conclusive evidence to support their use was found, suggesting that the removal of sterile dressing packs from the aseptic dressing procedure would not necessarily have a detrimental effect on patient care. In fact, in the experience of many wound care specialist nurses, and as reported at wound management conferences around the country, this already appeared to be accepted as a safe practice.
Taking into account the findings of the literature reviews and the financial costs involved with the continued use of sterile dressing packs, it was agreed that this study be carried out.
The study had a number of objectives:
- To determine current practice;
- To establish prescribing costs;
- To monitor the implementation of an updated aseptic dressing procedure;
- To measure changes in practice.
To achieve a representative sample, it was agreed that the three groups of nurses who are most likely to deliver wound care in the community should be included in the study - practice nurses, district nurses and nursing home staff.
Three general practices, one from each geographical locality served by the trust, were identified which were able to fulfil a number of inclusion criteria. The practices prescribed for district nurses, practice nurses and at least one large nursing home (60 beds or over) and were able to provide the data required via their computer systems.
The total practice population of the three trusts was 30,950.
A letter was sent to each practice, outlining why and how the study was being carried out, what its objectives were and requesting their involvement. All three practices agreed to take part. However, one practice withdrew from the study before any data collection had taken place. The reason given for this was that a new computer system had recently been installed and, as a result, the practice would be unable to provide the data required. It is interesting to note that this particular surgery was a dispensing practice. This suggests that there may have been a conflict of interest as revenue may be lost if dressing packs were no longer prescribed.
The remaining two practices had a practice population of 23,150. Owing to time constraints it was not possible to recruit another practice to the study.
A short questionnaire was designed by the wound care team in liaison with representatives from each of the participating staff groups and the trust's clinical audit department. This was used to establish current practice.
The questionnaire recorded the following data for all patients presenting at one of the practices with a wound on which a sterile dressing pack was used:
- Type of wound;
- Aetiology of wound;
- Current treatment;
- Clinical history.
It also asked staff about situations other than wound management where a sterile dressing pack would be used, and about awareness of sterile dressing packs being requested by non-nursing staff.
Prospective data was collected in each clinical area during one week in June 2000. On return of the data, the practice documented was compared with good practice outlined in South Staffordshire Healthcare NHS Trust's wound management procedures. This exercise was performed by the wound care sister and validated by the clinical nurse specialist.
A new aseptic dressing procedure was written by the clinical nurse specialist wound care and the trust's infection control nurse (Box 1). This did not involve the use of a sterile dressing pack, yet still implemented the principles of prevention of cross infection (Department of Health, 1998). The only difference between this procedure and the original aseptic dressing procedure was that the plastic sheet, which comes with the sterile dressing aid (gloves), is used to form a sterile field, instead of a sterile dressing pack. It was well documented that the use of other components of sterile dressing packs (cotton wool balls and gauze squares) do not constitute best practice in wound management (Morgan, 1998).
Before the new procedure was implemented, a member of the wound care team visited each of the clinical areas to deliver an education package introducing the new procedure. This included a clear explanation of the rationale underpinning the procedure and practical demonstration of its implementation in practice. Time was also included for question, practice and discussion.
Once the new procedure had been introduced and relevant education delivered, clinicians in all three areas were given three months in which to implement the new procedure. Practice was then re-audited during one week in October 2000.
Data for this audit was collected using a questionnaire, which requested the same information as that distributed at the start of the study. In addition, clinicians were asked to comment on their experiences of implementing the new procedure in practice.
To determine the effect of introducing the new aseptic procedure, numbers of dressing packs used by each practice in November 1999 and November 2000 were ascertained. This was to provide information from before and after the study, taken at the same time of year in order to accommodate seasonal differences. The information was obtained from South Staffordshire Health Authority, using the Prescriptions Analysis Costs and Trends data (PACT). PACT data is produced by the Prescription Pricing Authority as a cost containment audit and quality review tool. It contains details of all prescriptions issued, but no patient identifier is available from this source.
Taking into account the type and aetiology of the wound, current treatment and clinical history, the use of an aseptic dressing procedure was appropriate in only 43% of cases in the first round of data collection. This figure increased to 62% following education and implementation of the procedure. However, it should be highlighted that South Staffordshire Healthcare NHS Trust's clean and aseptic dressing procedures, guidelines for their use and the education package underpinning them had not been available to practice nurses or nursing home staff before this study.
Following the introduction, education and implementation of the new aseptic dressings procedure, there was a marked reduction in the number of sterile dressing packs used (Fig 1). This resulted in considerable cost savings (Fig 2). Situations other than wound management where sterile dressing packs were used included catheterisation, catheter care and eye care.
A review of South Staffordshire Healthcare NHS Trust's procedure manual concluded that this usage was inappropriate in all cases.
Requests for sterile dressing packs made by non-nursing staff were confined to the nursing homes involved only.
Comments from the nurses regarding implementation of the new procedure were positive. These included 'sterile dressing packs are outdated, with what equipment is provided inside them. Once we get used to the new procedure it will be a lot quicker and easier' and 'we are already doing most of the new procedure. There are no problems and there is no necessity to use sterile dressing packs.'
It is acknowledged that this is a small study, with a small numbers of patients involved. Had data collection taken place over the period of one month each time instead of one week, and another practice been recruited to replace the one that withdrew, the sample size may have been bigger. However, despite the small numbers involved the study demonstrates the following:
- A reduction in the numbers of dressing packs used;
- A reduction in the associated prescribing costs;
- An increase in the appropriate use of the sterile dressing procedure;
- Sterile dressing packs were being used in procedures other than wound management;
- Requests for sterile dressing packs were being made by non-nursing staff;
- Positive comments from the nursing staff on the new procedure;
- That there is little, if any evidence to support the use of sterile dressing packs in wound care.
Although inappropriate use of sterile dressing packs increased by 19% following the education and implementation of the new aseptic procedure, in 38% of cases the use of aseptic dressings procedure was still inappropriate. This highlights the need for further education of nurses and other staff.
A reduction in the number of dressing packs used was reported, with associated cost savings. A projected cost saving of approximately £100,000 a year was identified if the new procedure were to be implemented across the three primary care groups served by the community trust at the time of the study. A number of situations other than wound management were identified where sterile dressing packs were being used inappropriately. This again highlights the need for further education.
Requests for sterile dressing packs by non-nursing staff were confined to those working in nursing homes. This suggests that nursing home managers should be encouraged to consider who is responsible for ordering such items and why. Following the implementation of the new procedure, comments received from staff were all positive. Staff appeared to be eager to implement the procedure across their practice.
This study represents a good example of challenging tradition in nursing practice. Although dressing packs have been used in wound management historically, there does not appear to be any evidence to support their use. However, a larger-scale study is required to ensure there are no detrimental effects on patients as a result of the implementing the new procedure.